utilitarian, these programs must be efficiently operated; that is, laboratory tests, diagnostic procedures, and other examinations must be performed and interpreted rapidly, and screening facilities must be readily available to the population being screened. Experience in outpatient clinics in State and municipal hospitals for the indigent has shown that when diagnostic tests are interpreted on the same day they are made and the patient is informed immediately of the results and need for treatment, treatment is more likely to be accepted.

The multiphasic screening program of the Kaiser Foundation is a step in the right direction. Certainly, results of laboratory tests performed on completely automated equipment, including the electrocardiogram, can already be evaluated by computer, and the same will soon be possible for chest X-rays.

Automated systems will be necessary in screening programs for several reasons:

(1) People will demand that periodic health examinations be done quickly, with minimum loss of time from other activities;

(2) Physicians are becoming increasingly dependent upon such devices, and future physicians will be unwilling to use current laborious, time-consuming, and uninteresting methods to perform health examinations;

(3) As people become more health conscious and periodic health examinations become routine, health personnel will be inadequate to do these examinations;

(4) Although most of a physician's time is spent handling psychosomatic disorders, organic disease must be excluded before a psychosomatic origin can be established.

Preventive medicine is not my field, and I am sure your committee knows a great deal more about the health needs of the elderly than I. My interest in the practice of medicine in the future derives from my responsibility as a medical educator to prepare our graduates for the type of medicine they will have to practice. The predictions made in my address to our Owl's Club were extrapolated from the experiences of the past 75 years. I am enclosing a reprint of the address.

Sincerely yours,

OSCAR CREECH, Jr., M.D.

TUFTS UNIVERSITY,

SCHOOL OF MEDICINE,

OFFICE OF THE DEAN,

Boston, Mass., September 16, 1966.

Senator MAURINE B. NEUBERGER,

Chairman, Subcommittee on Health of the Elderly,

U.S. Senate, Washington, D.C.

DEAR SENATOR NEUBERGER: Thank you for your letter of August 24, 1966, containing a series of questions related to multiphasic screening and health maintenance.

First, I would like to make two preliminary observations:

1. Health maintenance has so far been most successful with those population groups who are not able to reject it, namely infants, students, employees, soldiers, and prisoners.

2. A serious lack already exists between much basic knowledge of disease and the application of this knowledge to various population groups in a preventive fashion.

1. Multiphasic screening. Is there a place for it in health care? Of course there is an important place for it. I believe it should be located within the framework of a comprehensive health center. In the Commonwealth of Massachusetts a substantial multiphasic screening program was developed by the commissioner of health without the initial approval of the Massachusetts Medical Society about 12 years ago. Although the program turned up a great deal of illness, it also produced much bitterness from patients and practicing physicians. The program was finally discontinued. Patients generally are naive and have no concept of margin of error and fluxation of values. Physicians who are not part of the multiphasic system are often angered by the implication to the patient that they have cared for him for years without having discovered a disease. Finally, many patients in the United States have no semblance of a personal physician and would be very alarmed by any positive result at a multiphasic screening examination without a prompt and ready outlet for their anxiety.

2. No members of the Tufts faculty have been actually involved in multiphasic screening.

3. During the next 2 years, the Department of Preventive Medicine of Tufts University School of Medicine will be involved in creating health maintenance programs for the entire population (6,000) at Columbia Point Housing Development and poor families from North Bolivar County, Miss. These programs will be carried out within the context of family center comprehensive center.

4. Individuals with special knowledge of multiphasic screening:

Dr. Valdo Getting, University of Michigan, School of Public Health, Ann Arbor, Mich.

Dr. Edward M. Holmes, Jr., Medical Director for Region 4, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, Region 4, Atlanta, Ga.

Sincerely yours,

Hon. MAURINE B. NEUBERGER,

Chairman, Subcommittee on Health Study of the Elderly, U.S. Senate Office Building, Washington, D.C.

DEAR SENATOR NEUBERGER: I have received your letter of August 24 with regard to the hearings which your committee has scheduled for September 20, 21, and 22 on the subject of multiphasic screening programs. While the interval until that date is very short, I am confident that you will develop sufficient information to be of help in preparing for those hearings. My own response to the four questions you have addressed to me follows. I hope you will find something of value in it.

(1) The principle of multiphasic screening is completely valid and there is, indeed, a definite place for it in our country at this time. I do think it is important, however, to note that multiphasic screening is essentially a technique for combining and compacting, objective measurements of the human body. It does not, of and by itself, “prevent" anything and those who would misrepresent it in this fashion do it a disservice. In other words, when multiphasic screening reveals a positive finding, if it is sustained, it indicates the presence and not the imminence of an abnormal situation, illness, or disease. Naturally, as a tool which can result in remarkably early diagnosis, it may have inestimable value in preventing secondary complications or expressions of an illness when it results in early therapy for the primary condition.

In my opinion, there are three routes by which multiphasic screening programs could be effectively established. First, it could be accomplished within the private sector of the practice of medicine. Second, it could be accomplished by basing the multiphasic screening programs in medical schools and certain other nonprofit health facilities. Third, it could be done under the jurisdiction of the U.S. Public Health Service. Within the private sector, the very same ethics which protect and maintain the integrity of competent medical practice on a personal basis will probably preclude the development of multiphasic screening programs. There is one exception, however. That is when a group of physicians elects to service a clientele through a closed-panel system. The Kaiser Foundation in California is a prototype of such an arrangement. With regard to medical schools, their primary objective is undergraduate medical education. Since the objective of a multiphasic screening program is primarily service (unless we conclude that the education of the patient about himself should be the proper concern of the medical school) there is a conflict here which would have to be resolved. The recent passage of the regional centers program has resulted in a redefinition of the service aspects of medical schools in a manner which will permit a broader approach to these problems than ever before. Hospitals and certain other nonprofit health facilities might accept this role although such a suggestion would likely provoke strong objections at a time when hospitals are using all possible approaches to reduce the total number of professional persons who are retained on a salaried basis. The Bureau of State Services of the U.S. Public Health Service could, of course, handle such a program very nicely. Indeed, there is rather good reason to think that "monitoring," rather than the specifics of treatment, properly belongs with the Public Health Service.

With respect to your question about the problems of acceptance by the public and the medical profession, let me say that I can think of no reason why a multiphasic screening program would not receive both prompt and enthusiastic acceptance by the general public. The medical profession, on the other hand, will likely object to the program although I would be quite surprised if the objection were very strong. The concern of the profession would be that a multiphasic screening program could become an invasion of the practice of diagnostic medicine, which is carried out under the jurisdiction of persons who might not be licensed physicians, and that the impersonal and machinelike approach of multiphasic screening is a poor substitute

for the interpersonal relationship on which the traditional concept of the practice of medicine has been based in our country. Both objections have real validity. Accommodation to the first should not be difficult if the accreditation and standardization of the laboratory testing procedures were assigned to the jurisdiction of appropriately trained and registered health personnel. Similarly, it may be neces sary to consider assigning senior responsibility for the operation of individual multiphasic programs to licensed physicians in order to allow for the absorption of liability which may be involved should the performance of a diagnostic test result in a patient accident or, indeed, even a fatality. (I am assuming, of course, that if a multiphasic screening program were established, the approach to the program by the patient would be on a completely voluntary basis and the results of the testing procedures would be forwarded directly to a physician chosen by the subject patient.) As regards the impersonality and machinelike approach to diagnostic medicine, this is less serious provided that rather rigid guidelines were developed to insure that any steps which might be taken toward the interpretation of abnormal findings must be taken outside of the setting of the multiphasic screening program itself because of the personal nature of the problem. My earlier suggestion that results should be forwarded directly to a physician chosen by the patient not only insures that the personal element will be injected into the situation but also preempts the development of a false sense of security by the patient who has been informed directly that his testing was negative. Such a policy will also prevent protracted and unnecessary worrying by a patient who has been informed that certain tests may be abnormal, at least until this has been clarified by the physician.

(2) There are no members of our faculty or staff who have participated in the organization or operation of a multiphasic health screening program since the college of medicine at the University of Arizona is still in an early stage of development.

(3) At this time, I would not wish to make suggestions as to why effective screening should be substantially different for persons on either side of the age of 60.

(4) We have no persons working in our school at this time who have special knowledge of, or interest in, this subject.

If you have found any of the above material to be of sufficient interest or help that you would like to have any of it developed in additional depth, then I hope you will feel entirely welcome to call upon me. Very sincerely yours,

MERLIN K. DUVAL, M.D.

UNIVERSITY OF ARKANSAS,

SCHOOL OF MEDICINE,

Hon. MAURINE B. NEUBERGER,
US. Senate,

Washington, D.C.

OFFICE OF THE DEAN,

Little Rock, September 7, 1966.

DEAR SENATOR NEUBERGER: I felt honored to receive your letter of August 23 which you wrote me in your capacity as chairman of the

Subcommittee on Health of the Elderly. First, let me say that I have no qualifications or experience that makes me an expert regarding multiphasic health screening. Neither am I aware of any member of the faculty of this school of medicine having been involved in the development or operation of a multiphasic health screening program. Having disqualified myself as an expert, I am taking the liberty to comment as an individual with a deep interest in medicine.

I read with real interest the material which accompanied your letter. Certainly, Senator Williams should be complimented upon the masterful and scholarly manner with which he presented this subject to the Senate. The comments by leaders in the field of public health which accompanied Senator Williams' speech were quite convincing, and these are the words of individuals who are experts.

Screening by certain tests has, of course, been carried out for a selected population for considerable time. This selected group has been that segment of the population coming under good medical care. Whatever his complaint, an individual attending the outpatient clinic or admitted to the hospital of this institution will be screened for syphillis, diabetes, anemia, hypertension, cardiac abnormality, lungs by chest X-ray, and others. These screening measures not infrequently pick up abnormalities unrelated to the patient's presenting complaint, and these abnormalities would be missed without these screening techniques. Application of such techniques to the uncomplaining population could not help but bring to light many instances of unsuspected and early disease.

The selection of specific tests to be incorporated in a multiphasic screening program would require a great deal of professional study. I would consider it a mistake for any specific tests to be designated by legislation. Rather, it would seem more appropriate for the legislation to spell out the objectives desired and the age groups to be considered. Furthermore, there are some diseases which when found early lend themselves to treatment, and others which still are beyond medical science to deal with effectively. Of course, the finding of a significant volume of untreatable disease stimulates research in that particular field. The point I would make in this regard is the matter of objective. It would seem appropriate for legislation to give some guidance as to whether or not there should be concentration on diseases which lend themselves to therapy.

As a practical matter, I believe Senator Williams paid less attention to the matter of manpower problems relative to such a program than he should have. We all want to develop and implement every program possible that will contribute to the health of our people. However, at the level of implementation we are finding increasing difficulty in finding the people to do the job. With each new program, I believe we must make the provisions necessary to train the appropriate people to carry out the desired plan of action. From where I sit, training people means facilities and faculty; and provision of these requires more funds than we have had at our disposal to date.

Thank you very much for writing to me, and I have appreciated this opportunity to reply.

Sincerely yours,

WINSTON K. SHOREY, M.D., Dean.